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General NPI Number Information
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NPI Number | 1770643975
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Entity Type | Individual
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Provider Name | LISA MORTENSEN MS ATC
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Gender | Female
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 405 S 100 E STE 102
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-2751
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Country | US
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Telephone | 801-785-9991
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Fax | 801-785-9417
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Provider Business Mailing Address
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Address Line | 1915 W 140 S
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City | OREM
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State | UT
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Zip | 84058-2062
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Country | US
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Telephone | 801-812-2736
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 6332468-4810
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License Number State | UT
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